nursing home in Colorado Springs, CO
Mount St Francis Nursing Center
7550 Assisi Hts, Colorado Springs, CO 80919 · (719) 598-1336
CMS overall star rating
- Health inspections★★★★★2
- Staffing★★★★★4
- Quality measures★★★★★2
- Abuse citation
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Mount St Francis Nursing Center at a glance
Mount St Francis Nursing Center is a 110-bed non-profit nursing home in Colorado Springs, Colorado (El Paso County).
CMS gives it 2 out of 5 stars on its overall star rating, worse than the Colorado average of 3.2.
Residents receive about 3.5 hours of nursing care per day (1.2 of them from registered nurses), worse than the state average of 3.7 hours.
Its most recent standard health inspection (March 6, 2025) found 5 health citations. The Colorado average is 8.7.
It has not received a federal fine in the past three years.
Nursing staff turnover is 55% per year (state average 47.1%).
Facility details
- Type
- Nursing home
- Ownership
- Non Profit - Corporation
- Beds
- 110
- Certified for
- Medicare and Medicaid
- Chain / affiliated entity
- Commonspirit Health
- Medicare-certified since
- July 1, 1994
- Resident/family council
- Resident
- County
- El Paso County
- CMS Certification Number
- 065325
Ratings
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 2 / 5 | 3.2 / 5 | 3 / 5 | Worse |
| Health inspection rating ⓘ (higher is better) | 2 / 5 | 2.7 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 4 / 5 | 3.2 / 5 | 2.9 / 5 | Better |
| Quality measures rating ⓘ (higher is better) | 2 / 5 | 4.1 / 5 | 3.6 / 5 | Worse |
| Long-stay quality rating (higher is better) | 2 / 5 | 4.1 / 5 | 3.8 / 5 | Worse |
Staffing
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 3.50 hrs | 3.72 hrs | 3.86 hrs | Worse |
| Registered nurse hours per resident per day (higher is better) | 1.18 hrs | 0.82 hrs | 0.69 hrs | Better |
| Nurse aide hours per resident per day (higher is better) | 1.98 hrs | 2.21 hrs | 2.32 hrs | Worse |
| Weekend nurse staff hours per resident per day (higher is better) | 3.12 hrs | 3.29 hrs | 3.42 hrs | Worse |
| Nursing staff turnover (yearly) (lower is better) | 55% | 47.1% | 45.8% | Worse |
| Registered nurse turnover (yearly) (lower is better) | 43.2% | 44.6% | 42.9% | Average |
| Administrators who left in the past year (lower is better) | 2 | 0 | 1 | Worse |
Inspections
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 5 | 9 | 9 | Better |
| Citations from complaint investigations (latest cycle) (lower is better) | 2 | 2 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 40 | 74 | 80.6 | Better |
Penalties
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
| Total fines in the past 3 years (lower is better) | $0 | $22,802 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
Size
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 110 | 94 | 107 | |
| Average residents per day | 95 | 75 | 86 | |
| Occupancy | 86.7% | 80.7% | 80.9% |
Long-stay residents
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 7.1% | 3.4% | 3.2% | Worse |
| Long-stay residents with pressure ulcers (lower is better) | 5% | 3.4% | 4.6% | Worse |
| Long-stay residents given antipsychotic medication (lower is better) | 16.2% | 20% | 15.4% | Average |
| Long-stay residents with a urinary tract infection (lower is better) | 1.1% | 1.4% | 1.6% | Better |
| Long-stay residents with a catheter left in the bladder (lower is better) | 0.5% | 0.6% | 0.8% | Better |
| Long-stay residents needing more help with daily activities (lower is better) | 32.3% | 13.4% | 13.9% | Worse |
| Long-stay residents whose walking worsened (lower is better) | 24.4% | 13.3% | 14.1% | Worse |
| Long-stay residents who lose too much weight (lower is better) | 4.4% | 4.7% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 9.8% | 8.8% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.1% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 14.6% | 11.5% | 19.5% | Better |
| Long-stay residents with new or worse incontinence (lower is better) | 23.9% | 21.2% | 19% | Worse |
| Long-stay residents given a flu vaccine (higher is better) | 100% | 94.7% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 99.7% | 93.5% | 93.6% | Better |
Short-stay residents
| Measure | This facility | Colorado avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Short-stay residents newly given antipsychotic medication (lower is better) | 4.8% | 1.6% | 1.6% | Worse |
| Short-stay residents given a flu vaccine (higher is better) | 85.2% | 75.6% | 79.8% | Better |
| Short-stay residents given a pneumonia vaccine (higher is better) | 88% | 76.4% | 82% | Better |
Inspection citations
State inspectors cited this home for 20 health deficiencies and 4 fire safety deficiencies in the inspection records CMS currently publishes. None were rated as causing actual harm to residents.
| Date | Citation | Severity | Status |
|---|---|---|---|
| March 6, 2025 Fire safety | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Tag E0015 | F Potential harm, widespread | Corrected April 5, 2025 |
| March 6, 2025 Fire safety | Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Tag E0036 | F Potential harm, widespread | Corrected April 5, 2025 |
| March 6, 2025 Fire safety | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Tag E0039 | F Potential harm, widespread | Corrected April 5, 2025 |
| March 6, 2025 Fire safety | Establish an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Tag E0001 | F Potential harm, widespread | Corrected April 5, 2025 |
| March 6, 2025 Standard | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Tag F0730 | E Potential harm, pattern | Corrected April 5, 2025 |
| March 6, 2025 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | D Potential harm, isolated | Corrected April 5, 2025 |
| March 6, 2025 Complaint | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | D Potential harm, isolated | Corrected April 5, 2025 |
| March 6, 2025 Complaint | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies · Tag F0622 | D Potential harm, isolated | Corrected April 5, 2025 |
| March 6, 2025 Standard | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Tag F0761 | D Potential harm, isolated | Corrected April 5, 2025 |
| November 30, 2023 Complaint | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Tag F0882 | F Potential harm, widespread | Corrected January 17, 2024 |
| November 30, 2023 Complaint | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected January 5, 2024 |
| August 17, 2023 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | F Potential harm, widespread | Corrected September 16, 2023 |
| August 17, 2023 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected September 16, 2023 |
| August 17, 2023 Standard | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Tag F0804 | E Potential harm, pattern | Corrected September 16, 2023 |
| August 17, 2023 Standard | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Tag F0806 | E Potential harm, pattern | Corrected October 30, 2023 |
| August 17, 2023 Standard | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 | D Potential harm, isolated | Corrected September 28, 2023 |
| August 17, 2023 Standard | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Tag F0695 | D Potential harm, isolated | Corrected September 16, 2023 |
| August 17, 2023 Standard | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Nursing and Physician Services Deficiencies · Tag F0726 | D Potential harm, isolated | Corrected September 16, 2023 |
| August 17, 2023 Standard | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Tag F0744 | D Potential harm, isolated | Corrected September 16, 2023 |
| August 17, 2023 Standard | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Tag F0563 | D Potential harm, isolated | Corrected November 15, 2023 |
| August 17, 2023 Standard | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Tag F0676 | D Potential harm, isolated | Corrected September 16, 2023 |
| August 15, 2019 Standard | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Tag F0676 | E Potential harm, pattern | Corrected September 18, 2019 |
| August 15, 2019 Standard | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Tag F0658 | D Potential harm, isolated | Corrected September 18, 2019 |
| August 15, 2019 Standard | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected September 18, 2019 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with potential for minimal harm; D–F potential for more than minimal harm; G–I actual harm; J–L immediate jeopardy to resident health or safety. How to read inspection citations.
Fines and payment denials
CMS reports no federal fines or payment denials in the past three years.
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| COMMONSPIRIT HEALTH Organization | 5% or greater direct ownership interest | 100% | 11/28/2023 |
| MCGINN, THOMAS Individual | corporate director | NOT APPLICABLE | 11/28/2023 |
| MELFI, MITCH Individual | corporate director | NOT APPLICABLE | 11/28/2023 |
| MORISSETTE, DANIEL Individual | corporate director | NOT APPLICABLE | 11/28/2023 |
| DONOHOE, THOMAS Individual | corporate officer | NOT APPLICABLE | 11/28/2023 |
| GAASCH, ANDREW Individual | corporate officer | NOT APPLICABLE | 11/28/2023 |
| CARPENTER, DEBRA Individual | operational/managerial control | NOT APPLICABLE | 11/28/2023 |
| COMMONSPIRIT MOUNTAIN REGION Organization | operational/managerial control | NOT APPLICABLE | 11/28/2023 |
| BEHRE, ALMAZ Individual | w-2 managing employee | NOT APPLICABLE | 11/28/2023 |
| SHEPHERD, DAVID Individual | w-2 managing employee | NOT APPLICABLE | 11/28/2023 |
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Frequently asked questions
What is Mount St Francis Nursing Center's rating?
Mount St Francis Nursing Center has 2 out of 5 stars on the CMS overall star rating. The average for Colorado nursing homes is 3.2 stars.
How many inspection citations did Mount St Francis Nursing Center receive?
Its most recent standard health inspection found 5 citations, compared with a Colorado average of 8.7. Every citation is listed on this page with its severity.
Does Mount St Francis Nursing Center accept Medicare and Medicaid?
CMS lists it as certified for: Medicare and Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Mount St Francis Nursing Center?
It is non profit - corporation and part of Commonspirit Health. The ownership section on this page lists the owners and managers reported to CMS.
Where is Mount St Francis Nursing Center and how do I contact it?
Mount St Francis Nursing Center is at 7550 Assisi Hts, Colorado Springs, CO 80919. Phone: (719) 598-1336.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.